[applause] >> this month watch c-span's coverage of the 2016 republican and democratic national conventions, and every saturday night at eight eastern we will look back at past conventions and the presidential candidates who went on to win their parties nomination. this saturday we'll focus on incumbent president who ran for reelection. dwight eisenhower in 1956 republican convention in san francisco. the 1964 democratic convention in atlantic city with lyndon johnson. richard nixon at the 1972 republican convention at miami beach. the 1980 democratic convention with jimmy carter in new york city. george h. w. bush at the 1992 republican convention in houston. bill clinton in chicago for the 1996 democratic convention, and the 2004 republican convention

in new york city with george w. bush. past republican and democratic national conventions saturday nights at eight eastern on c-span. >> if we're going to invest additional $100 million into higher education in the commonwealth we got to change way we deliver education and expect more from the dollars we are getting spent sunday night onto a day, gerard robinson talks about the state of education in the u.s. spent there's a body of literature that's pretty clear that they're certain courses you should take, math, science and english that should be listed expect to be successful in college. to simply accept students who have not filled of that curriculum obligation, to let them into school i think is doing a great disservice to them and it's selling the effort of affirmative action which is something i support. >> sunday night on c-span's q&a.

>> the u.s. senate is about to meet and a pro forma session. no legislative work as expected. now live to the senate floor. the clerk will read a communication to the senate. the clerk: washington, d.c., tuesday, july 5, 2016. to the senate: under the provisions of rule 1, paragraph 3, of the standing rules of the senate, i hereby appoint the honorable cory gardner, a senator from the state of colorado, to perform the duties of the chair. signed: orrin g. hatch, president pro tempore. the presiding officer: under the previous order, the senate stands adjourned until 10:00 a.m. on wednesday, until 10:00 a.m. on wednesday,

.. in colorado, in my text,

ohio. >> now i look at proposed changes to medicare payments or the senate finance hearing includes testimony from dr. patrick conway for the center for medicare and medicaid services. he talked to hospitals and medical finders would be affected by the new payment plan. this is an hour and a minute. -- 40 minutes.

>> i would like to welcome everyone to this morning's hearing that will allow the committee to examine the obama administration's proposed medicare part b demonstration. i would like to thank dr. patrick conway from the center for medicare and medicaid services for testifying. today's topic is very important. the proposed cms demonstration project would radically alter the way that medicare pays for drugs and biologic treatments have positions on current positions described minute mr. in the outpatient settings that are covered under part b. typically, these are drugs and treatments tested in a physician's office or hospital. they are used to treat vulnerable beneficiaries with serious medical conditions such as cancer, macular degeneration, rheumatoid arthritis, primary immunodeficiency diseases in a number of rare illnesses.

they have proposed demonstrations public this past march. i have made my opinion very clear. i believe this experiment is ill can be then likely to harm beneficiaries. it is no breach on the part of cms that in my opinion is the anti-agency statutory authority, extends nationwide and requires on medicare part b providers to participate. as we all know, the experiment would change the system in two phases, both of which are very troubling and that's putting it kindly. inherent concerns like to hear an explanation or cms as to why they believe their new payment changes would not hire medicare beneficiaries. so far what they have given us? any such acts donation or justification. that is not all that is missing from the elements of the demonstrations made public. indeed, this proposal, i'm being

kind with that description, not only what is and that, but what has been left out. but this proposal, cms has not indicated conditions in which they have the option to prescribe a high or low cost drug that has the same patient benefit. in addition, cms has not provided an analysis of how many position would lose money purchasing needed drugs. they have not provided an analysis of how often physicians would have to refer beneficiaries to the less convenient, more costly hospital outpatient setting. cms has not yet indicated how it will assess the impact on access and quality poster in the course of the demonstration, the formal valuation of it. not surprisingly, the proposed experiment has been widely condemned by experts and

stakeholders almost immediately after his proposed demonstration was released, we received an order from 300 day colder organizations asking for help in getting cms to withdraw the proposal. these organizations include the arthritis foundation, the caregiver action network, and immune deficiency foundation the lung cancer alliance and the national alliance for mental illness. the organizations that have reached out with concerns about how this proposal represents patients who suffer from diseases treated by these drugs, including cancer, arthritis, mental illness and hiv represent the physicians who treat the patients with these devastating conditions, including oncologists, from a technologist and author knowledge is. we've heard many of the same concerns from constituents in utah. many utahans feel the proposed demonstration would deprive them from the drugs that buy straight

hair conditions that require them to travel great distances to incur expenses to receive the needed care. obviously utah is not alone here. patients and providers from virtually every state have weighed in on this matter which all the republican members of the finance committee sent a letter to the administrator, urging him to withdraw the proposal. 14 senators from the only senate committee with oversight jurisdiction detail a thoughtful letter to cms about their proposal. how did the agency respond? we have received what essentially amounts to a letter thanking committee members for sharing their views and noting that cms will consider all of the comments. it could not have been more dismissive and its tone. that is the level of attention and seriousness of cms describes oversight of congress. sadly, this is not an isolated incident.

her seven years now, the entire obama administration has taken on an stonewalled or flat-out ignored oversight efforts on the part of the finance committee republicans. there are countless examples, sometimes the agencies showed disregard for the love like when they refused to provide any meaningful response to numerous inquiries about illegal reinsurance payments issued under the so-called affordable care act. other times they discount oversight role entirely, like when they deny finance committee staff access to last week's medicare and social security trustees report until the reports, i should say, until the first conference putting the administration's own misleading spin on the reports is well underway. i have on numerous occasions in writing like this and also expressed hope the admin is nation as a whole would change his ways and become more cooperative and transparent.

i've asked countless nominees that have come before the committee to commit to being responsive to senators inquiries. and over seven years the unprecedented level of disregard has continued unabated. in a short time left with this administration, and what renewed these costs for more cooperation and responsiveness today. i feel quite certain there are no new improvements on the immediate horizon. we have a high-ranking administration official before us today. at the very least we can finally get straight answers to the many questions raised by cms part b proposal. dr. conway stated in early may interview on the proposed demonstration that cms will interact with congress and take feedback and make adjustments as necessary, unquote. i do hope the conversation today will be more consistent with

that sentiment than the response shortly after the statement was made. senators on this committee and more importantly the constituents we represent deserve at least that much. with that, i will return to senator wyden for his opening remarks. >> thank you very much, mr. chairman. in my view, chairman, colleagues , what underlies this debate is we are entering an era where there are going to be miracle treatments and there are going to be curious. there are drugs on the market and close on the horizon that were science fiction not very long ago. the question for me, the foremost question is whether or not the american people are going to be able to afford these medicines with business as usual , too many of these treatments are going to clobber too many family budget and

threatened health programs across the country. and that was one of the big takeaways colleagues from the 18 month investigation senator grassley and i conduct it on a bipartisan basis into the rollout of one watt buster drug. it was a drug that treats hepatitis c and had a list price of $1000 a pill. i think that this is going to be the pattern, colleagues, for years and years to come absent reform. lots of cures and a big, dear? when it comes to access and affordability. now the hepatitis c drugs that senator grassley and i did our bipartisan inquiry into our not the primary focus of today's

hearing. today, the committee is going to examine a demonstration project of medicare part b that covers outpatient care. part b pays for a small share of the drugs many seniors are prescribed in the demonstration would affect the way those drugs are paid for. the demonstration has brought to the forefront additional major questions about how the country is going to afford to address the trend of escalating pharmaceutical prices. the fact is too many seniors are getting pounded today by prescription drug bills. in my view, there is an enormous amount of work that has to be done to guarantee that seniors have affordable access to the medications they need. medicare part b seniors are often hit especially hard because their share of drug cost

conseco insurance and that of the co-pay. that means rather than a flat manageable fee, some older people face a huge burden stuck paying a percentage of a drugs total cost. i look at that word in the same way i look at the rising out-of-pocket costs for older people in medicare part d. for part d, i propose legislation that would establish an out-of-pocket cap to help protect older people. in my view, this committee ought to take a close look at ways to make sure seniors don't get pounded under par on trade part b as well. but this particular demonstration project, all of the finance committee democrats and i sent a letter in april to the acting administrator at the centers for medicare and medicaid services outlining key concern we have about the impact

the project is going to have on patient. at their core, our concerns were about making sure that older people who are especially vulnerable have access to lifesaving medications. protecting access especially important in rural america with a face fewer choices and lower quality of care. it is extremely important as love the project not resolved in patients being told they have to get treatment at the hospital for treatment is often more costly and less convenient. i letter said the demonstration project has to be in sync with the effort medicare is making to move towards treatment based on value rather than volume. when you focus on the value and efficiency of care, there is potential to raise the quality of care for older people while saving money at the same time.

i hope the committee will examine these issues as it looks at the medicare part b demonstration. i want to thank dr. conway for joining the committee here as well. we look forward to his testimony and members have a chance to ask questions. thank you >> thank you. i would need to introduce today's witness. dr. conway for medicare and medicaid services. dr. conway hooked a number of high ranking titles in those positions for health programs that provides services to 100 million people. two of those roles with designers serving as the agency's chief medical officer make him well-suited to testify on the agency's proposed part e drug demonstration. dr. conway was the director of hospital medicine and associate professor at cincinnati children's hospital.

he earned his medical degree from the college of medicine and completed his residency at the school children's hospital boston. thank you, dr. conway for taking the time today. we will be glad to take your statement at this time. >> thank you, sir. chairman hatch, ranking member wyden and members of the committee, thank you for the invitation to discuss medicare and medicaid services how medicare pays for drugs to support physicians and other clinicians and delivering higher-quality care to beneficiaries in the medicare program. we very much value the input and feedback we receive from congress and members of this committee and we are carefully reviewing the comments we receive from you in the public. partpart d drug spending has rin over time and heard from many stakeholders about access and the cost and value of prescription drugs.

to address concerns, cms issued a proposed rule to test a model with improving patient care and the value of medicare drug spending. this proposal alliance with cms innovation center statutory goal to test innovative payment delivery models that reduce expenditures while preserving or enhancing the quality of care. the proposal is part of the administration's broader strategy to encourage better care, smarter spending and how people paying for what works in finding new ways to court date and integrate care to improve quality is cms values and put in comments and looks forward to continuing to work with stakeholders to the rulemaking process in an ongoing manner to maximize the value of learning from the proposed model. we have received feedback from stakeholders on several issues including the size of the model, patient access and small practices in rural areas and the importance of input. we review all comments closely to determine whether adjustments

are needed. our goal is to be responsive to the public comments in and puts her in congress. many part b drugs including drugs furnished are paid based on the average sales price plus the 6% add-on payment. cms proposal outlines a new part b model that would test whether alternative designs may improve how medicare pays for prescription drugs and support positions on delivering higher-quality care. physicians can choose among several drugs and the current medicare methodology can create disincentives for doctors to select lower cost drugs. even when these drugs are as good or better for patients based on the evidence. among the approaches are the elimination of certain sadness that work against the selection of high-performing drug as well as positive incentives for the selection of higher performing drugs including reducing or eliminating cost sharing to improve patient access and use of the fact of drugs.

in the first phase, cms with test whether changing the current 6% add-on payment to 2.5% plus a flat fee of $16.8 per drug per day changes incentives and leads to value. the flat fee is calculated such that it is budget neutral. the second phase focuses on better outcomes and critical indicators to improve the value of drug payments by utilizing value-based pricing tools currently employed by private health plans, pharmacy benefit managers, hospitals and other entities to manage health benefits and drug utilization successfully. insurance beneficiary access to high-quality care and treatment at the forefront of the word. under the model beneficiaries have access to the same drug and complete freedom of choice of dog ears, hot as another suppliers. the proposed model would not affect drug coverage or any of their medicare.

it also includes a number of beneficiary protections. the model would include an exceptions process in addition to the standard appeals processes that would love to beneficiary provider comes by to explain my medicare is pricing policy is not appropriate for a given beneficiary as he can exception to the value-based pricing approach under phase two. cms to closely monitor access and outcomes during the model that would help ensure the beneficiaries looking to me to outback this part b drugs to millions of americans rely to manage chronic illnesses and treat acute condition. cms is committed to ensuring beneficiaries have access to the treatment they need while pursuing better drug value. loving folk, hhs and cms are committed to listening and working together with congress and other stakeholders to advance ideas to access,

affordability and innovations of all americans have access to the breakthroughs ahead. there are no easy answers to these multifaceted challenges, but there is a significant benefit to all of us are working together to find a solution. i appreciate theinterest and look forward to answering your questions. >> thank you, dr. appreciate your appearing before the committee and perhaps you can be of great help to understand some of these teams. you know, some people feel that cms uses the innovation center to undermine the prescription drug program. unilateraunilatera lly waived in the provision that prevents the federal government from negotiating drug prices. clearly such an undertaking would be a massive overreach. however, as we have seen on numerous occasions, the obama administration doesn't feel bound by the clear limits

provided in the statute. i take part dvery serious way, therefore i feel compelled to ask if the innovation center is working on any project or initiative that would allow the government to renegotiate prices or find any other change related to drug prices. as you are that had the innovation center, i would like to have a direct answer on not affect. >> we have no part b proposals at this time. you can't do the listening and with stakeholders across the health care system. so we have players come and manufactures to my providers, others that bring ideas to us across health care in the drug space. we view it as honorable to engage with those stakeholders,

to listen to ideas whether they come from congress or providers or payers of others to engage deeply under statutory mission, which is to engage in testing for my payment service models that the high likelihoolikelihoo d of improving quality and maintaining a lessening of amateurs. >> well, my stated position as far as i'm concerned, was cms needs to withdraw, you know, cms needs to withdraw the proposed part b rule shared by many. once again, over 300 stakeholder groups to be withdrawn unless immediately upon its release. without objection the letter of reference signed over by 300 patient and provider organizations will be included in this record. in addition to the stakeholders,

300 members of congress have urged cms to withdraw the proposal. many of the 1300 public comment was he pointed out serious flaws considering all of this backlash, it's pretty obvious that a cms does toward the very minute, it would be doing so again the interest and judgment of the vast majority of that person policymakers in this field. are you willing to acknowledge that this widespread opposition opposition -- that there is widespread opposition in withdraw this proposed rule? >> we take the input on congress and from stakeholders across the health system very seriously. that is why we proceeded through the rulemaking process, which is the most public and transparent processes that we can engage in. we are reviewing the comments now and plan to make adjustments

in the final rule. we are deep currently we have over 1300 public comments. we want to review those closely, carefully and thoroughly so that we can be as responsive and thoughtful as possible to the public input and the input from congress. >> well, it seems that within this role, cms is operating under premise that physicians are knowingly and purposely prescribing higher cost her a won a lower cost equivalent drug is available. the agency's view is apparently the most physicians and clinical decision are driven by maximizing profit incentive welfare. this is -- as in sunni this is

overly simplistic as that is what they are doing. given that you are a doctor, can you tell us the specific types of changes that physicians are due to make under the phase one payment scheme. please, if you will, provide specific conditions and drugs if you would do that for us. >> so, i am a practicing physician. i think the vast majority of physicians make prescribing decisions based on patient entrance and i want to state clearly i would want every position inclination to prescribe the medicine needed for their patient and we believe this proposal allows that to happen and we are looking close late out whether adjustments are needed because access to medications as you alluded to is a first priority for cms and for myself personally. in terms of the recently proposed this test, the current system can have decent vented

for physicians who may use lower-cost medication. for example, if a physician prescribes a $10 medication, the current 6% add-on is only 69 and that may not fully cover the cost of acquiring and administering the medication. so we were proposing this has two testing proposal to rethink would remove some of the current disincentives in the system to allow physicians clinicians to make prescribing conditions without regard to financial and vented and we clearly want positions and clinicians to provide the medicine that their patients need and for patients to receive those medicines. >> senator wyden. thank you, mr. chairman. dr. conway, let's go right to the question of prescription drug prices. for so many older people, i feel

like they are getting hit by a wrecking ball. many drug spending more than doubled between 2005 and 2015. increasing from $9.4 billion in 2005 to $22 billion in 20 team. now, medicare has, as you know, begun to move towards paid her quality and value rather than the volume of services. that has been something that has been recommended for ages and finally it is underway. but so far, prescription drugs have largely been left out of that equation that move towards paid for value rather than volume. i have been working on these issues since the days when i was codirector of the oregon gray panthers. i think it is appropriate to ask now is the issue of prescription

drug price is isn't addressed, aren't the cost going to become increasingly unaffordable for older people and really put a wrist for medicare guaranteed because that is what medicare is. it is a guarantee. won't this cost put at risk and medicare guarantee for future generations? >> thank you, senator biden. you know the part d spending has been in over eight growth year on year since 2007. i share your concern on access to medications. the current environment with co-insurance and potential for 20%: sharon as you can imagine for seniors on a fixed income, 20% of a $10,000 to whatever the cost might he can be a substantial financial hardship and can limit access to

medications. we also did propose this past because we had not today patti proposal directly paid for value. reducing pain for value is important as you said included in the drugs trade. so we made this proposal. we have other proposals include drugs that they part of the proposal, but we do think paying for value is important to mueller to across our health system of its hospitals and physicians can matter. >> does this threaten sustainability for future generations? >> so you know, it does have the potential, the cost of the medicare program has the potential to threaten the program and drugs are a substantial part of that cost. the reason i do this job quite

frankly and i care deeply about the 55 plus million americans and medicare, including my own mother and i want medicare to be open for my four children. i think we have to make major positive changes in the delivery system reform for that to be the case. >> now, i appreciate the agency's interest in looking at data to improve quality and now you and all aspects of a system that could strip should drugs. one of the turns that has been brought to members, the numbers on our side is that especially in a rural area, a small rural area with not exactly a large crack this. physicians can be put in a position where the cost of the drug is higher than the medicare payment. so what we are getting told on

our side is that it wouldn't be possible to afford to provide the medication to the patient. i would be interested in your response to this and also a fan responding, you could tell us what happened is that the case where the providers than their patient to a hospital outpatient program, which means then you have higher overall cost for both the older people and for medicare. tell me your response to that. members on our side have heard that an audit at your grief all talked about it. i assume colleagues on the other side as well. >> thank you for the question. we propose to include providers and small practices. however, we noted concerned aboutsome of these issues in the

proposal about making sure that we have both access to medication and treatment while we propose these changes. we will look closely at the public comment and determine whether any adjustments are needed a rural practice is there's law practice is. we are doing that review now in the types of things we would look at her and maintain to access to medications. we propose the monitoring plan similar to what we have used in other programs which conclude real-time claims data monitoring for access, patient outcomes and sheds inside of service. we would monitor that and if we needed to make adjustments, both at the macro level in the pilot if you will, but also an exceptions process to make adjustments down to the individual patient or practice level. thank you, mr. chairman. >> i only have two questions.

before i ask those, i went to thank you for coming today. as you have heard, there's many people. the administration has not been raised on it to congressional inquiries in addition to the letter signed by every republican on the committee i sent you to secretary secretary burwell april 29th. not givers is inadequate was on in my letter. i asked for clarification about whether the proposal constitute human subject research. and submitting that letter for the record and i hope that you had expedited answer to that. i'm number one question among dominicans parents i have over this proposal is a result of a hop on practices that ours mall, particularly in rural areas like most of my state of iowa or for those patients with rare

diseases. the first question, what is hard to the ms have with regard to treating patients served by smaller practices, those in rural areas and those with rare disease is. >> yes, senator, i share your commitment to his mall and rural practices. i grew up in a small town in texas with a two-person family is caring for her family. we did oppose to include rural and small practices, but we also noted in the proposed rule that we were concerned and focused on the access issues than we would address the fact that the issues at needed to restock comments about whether any adjustments or exclusion of other changes were needed for mall or rural practices. we will assess the comment and determine whether it just that there needed. >> number two, we have heard from a number of groups that

many patients and providers concerns in the proposal could have been avoided if patients had been included in the design of the demo at the fragment. what plans have been put in place to involve small practices in the world and where does the stakeholders in the future? >> yes, so we propose a process for phase two that would include input at multiple points, including patient input. we are looking at the comments now to determine if it is just concern has been needed for that price is. to give you a tangible example, i personally met with 20 plus patient and his number groups and do that teammate. that was about two weeks ago. they gave input on this proposal and things across the innovation center. that consumer input is probably the most critical input we get into these models because their focus is to be on the beneficiary, on the patient, on

the camera at all times. >> mr. chairman, i will yield back my time. thank you, dr. conway. the mac thank you, there. >> senator saddam now. thank you, mr. chairman. , ranking member, we appreciate your time and we appreciate your leadership on so many issues that affect all of us americans to chew in and just to underscore what has been talked about first and our ranking member talking about the letters that a number of sent to you. i am concerned that the scope of the current proposals is roger dennis typical of a demonstration project and just -underscore concerns raised about rural communities. i also share that. i understand the proposal is to drive providers towards prescribing more generic drugs in order to produce cost savings and i fully support that jack is.

i think as we look at those stated, there are other questions i have about a do we should be focused on more in order to be able to do that. that leaves me basically two questions in a broader and. first of all, the medicare trustees report released last week, i want to underscore for all of us that once again part b premiums could be unpacked by new enrollees and those who are dual eligible as we call them qualified for medicare and medicaid and the situation will learn more about this at a relief to the social security costs of living are just in pack on part d. mr. chairman, ranking member, i am very concerned about what could happen in terms of years and unintended increases in premiums related to that.

i just want to get that out there now is something we need to be very involved in. another issue raised by the report is the big issue, which is top about. as you noted in your testimony and 2015, cms and seniors pay 22 billion in part d drugs and according to a trustees report, nearly 89.5 alien in part d. if we talk about the elephant in the room, the area where we should be most focused his own part d in terms of the cost for seniors. an increase last year to 8.3. part b., which we talked about today, 2.4. when we are talking about 3.5 times smart growth, this is the area we need to be focused. dr. conway, is the goal is to drive down prescription drug

costs for seniors, for beneficiaries in general, are refocusing when we say part d., or should we be paving -- paid more attention to part b costs? >> yes, so in terms of part d, of course in the president's budget are a number of proposals for congress to cut better in this space. we are open to ideas at all times. we've had manufacturers come to us with ideas around value-based arrangement in part d. similarly, we've had providers in our next generation program talk about how they want to bring in arrangement that are voluntary between the provider and part d plans for new payment models. we are open to ideas from congress, from you, from

stakeholders across the health among ideas of what we should be doing in this space as well. >> thank you it just to underscore what i read a number who spend such a champion on these issues, i have heard from three can teach you in and the last few that have had hepatitis c. they weren't big enough to get their insurance company to pay for the expensive drug treatment, that they had insurance so they didn't follow five. in one case we were able to help someone get the medication that he needed to cure his disease. but in the other two instances, data not happened yet. that's not a good system of him and has to call the united states center to intervene for them to get the meds they need to be able to save their life. this is a huge, huge issue,

whether medicare, medicaid private insurance, we have to do much better and i hope we will be doing a hearing where the focus of the cost are and the areas in which seniors are most concerned. thank you, mr. chairman. >> senator robert. >> yes, thank you, mr. chairman. i would like to ask unanimous consent that a letter from over 20 patients including the national alliance on mental illness, the arthritis foundation, veterans health council and asia institute to the finance committee highlighted concerns be concluded in the record. >> without objection. >> when this committee was debating the health care act, i was concerned about several provisions that would decrease individual choice, open the dirt to government rationing. there are for rationing -- i am

not sure what to call them, the groups that you are one of them. one of these creations of this proposal and we have before us a demonstration project or task as the agency's press release called it could disrupt care from some of medicare's most vulnerable patients. by the way, thank you for being here today. i wanted to for share with you some comments and questions from a couple of issuance and can do. i leaned up over and part suffers from hypokalemia anemia and lucas or she wrote to me asking if anyone looking that the demonstration on the people that will impact. do any of them care that good honest americans will die without access to these treatments and the merely trying to save money by cutting costs? proposed actions will cause a degraded overall health outlook for many rheumatology arthritis

and other patients and most certainly than the death warrant for many patients like me. another constituent, bradley from wichita who wrote to cms experiment is an intrusion on the close relationship r..does have with patients and clinical decision-making. this experiment will backfire costing taxpayers even more for cancer care. according to the statute, to test innovative payment and service delivery models to reduce expenditures while preserving or enhance being the quality of care. that is why we are running >> into trouble. how are you going to ensure beneficiaries don't have trouble accessing appropriaappropria te time to treatment than a setting they prefer? the example of a patient going through rural oncology doctor sent to a hospital about 100 miles away. is there any data indicating these proposed payment changes

with payment outcomes? >> first goal of the innovations enter is to improve quality estes had to maintain quality. this is what i have been doing for 20 plus years in the public and private tour. the paramount is better patient outcomes. it is also to maintain or reduce expenditures. in the specific postal, we are proposing a value-based framework in phase two, which from the private sector, from private payers, providers has been demonstrated to focus on paying for a value in medication proposing to test that and we do believe they can maintain or improve quality and that is our primary focus on the quality side of the equation. >> on that issue, pardon me for

an iraq did, but i have very limited time. under the aca, but that jerry is prohibited from using comparative effect is an determining medicare coverage. however,in phase two, the cms plans to testing for drugs they somehow affect the bleak it treats different conditions. destiny believe it has the authority to waive this prohibition? are you doing what you should be doing? >> in terms of the innovation center, we are proposing to pay for value, which can be things like race day sharing arrangements based on outcomes. so it is consistent with the statutory ready to test new payment is service delivery models. it would highlight wrongly thousands of providers in every state in the nation in age to delivery system. we've got millions of patients that have reached the in many

instances demonstrated by independent evaluation report improved outcomes, improved care it. then we can certainly talk about that more. >> i appreciate that. the public comment period for the proposed rule concluded on may 9, cms is carefully can do to public comment on this proposal received by the comment. who value public input for stakeholders to maximize value for this model. that was mainly about medicare pricing fax and that is in direct conflict with the letter that we have earned 32 patient groups that say there is a lack of stakeholder input from this process had many problems with the demonstration could have been mitigated had they been involved on the front and. what we have here is a failure to communicate. i remain gravely concerned about how this demonstration are attached as the administration

calls it with access to care. i would like to reaffirm as we have requested. i would like to reaffirm my request to cms that draw this proposal. thank you, mr. chairman. >> well, thank you, senator menendez is not here. senator step dad -- suggs had. senator portman, you're an xp is the mac thank you. i appreciate you being here dr. conway and for your service. as you know, my wife is very involved and vice chair and incoming chair of one of her rate florida hospitals that i wish i could pay the same things about this proposal that i can about children's hospital. i'm concerned about it for some of the reasons stated already and that i want to ask you about one specific deep concern i have

about this is that they proposal. it's about a demonstration in my understanding will cover 75 and apart the medications which is hardly a mix here a minute. the control group is 25%. i was flicking through correspondence and letters and e-mails from some of mike issue is. a cancer patient very worried about her ability to get her camp or treatment. barbara lasky writes me a long letter about her immunodeficiency disease and what is going to happen to her to happen sooner. he's applied for disability now, already having a tough enough time. she has to go to adopt her. she's told her she goes to the doctor will be much more did or they won't be able to afford or provide it. a lot of deep concerns about it. the specific concern i am hearing from ohio is more about rural health centers. we've lost over 50 physicians

practices because you have been in ohio go into the big hospitals. this will continue that an accelerated. i think this proposal which is again not a dead tree should hardly have 70 factors that coverage, that a wholesale change is going to dislocate a lot of the people i represent and cause a huge concern among some that the smaller crack this is that are already having a tough time making it in the current health care environment with the affordable care act. let me ask you about something that concerns me about your specific postal that perhaps you are not aware of. i assume if you are aware of it, you wouldn't be doing it. this is a revenue neutral proposal. you can't reimburse that for some of these again outpatient clinics we are talking about, several providers and no one who

can have a tough time making it. you increase reimbursement and other areas in order to make a revenue neutral. one of the places you increase reimbursement with regard to prescription drugs used for pain management. specifically, you have a dramatic in recent reimburse and then did for the kinds of pain medication that is addictive and that is causing much of the problem we have now with this opioid epidemic in ohio and around the country. then they give you some numbers on that in case you are not aware of it. the expected impact on pain management medication you are seeing an increase of 36.9% and 33.7% versus a cut on oncology drugs five minus .6%. so it is a dramatic increase in acting the whole basis of your

proposal is that if the reimbursement is cut, there is less utilization. that is part of how you try to save money. on the other hand, you are increasing reimbursement at a time when i ate there is a general sense in the administration because we worked with them closely that there's too much overprescribing of certain kinds of pain medication that is addictive, that is causing so much of the opiate grace is. the recovery act which is passed by 94 to one deals with enhanced drug monitoring. there is generally a view at hhs state problem. we work closely with them. senator whitehouse and i are co-authors. this seems to run counter to that. i'm concerned to hear from other colleagues, another roberts and others about providers is a concern of nine. i have a bigger concern about the fact that this proposed rule, what you say is to drive

the most effect of drugs, the reimbursement for this particular kind of opioids, this increase could have saved very negative impact and increase the problem with this opioid epidemic. for those who don't follow it closely, it is believed four out of the five addicts overdosing today at 129 lose their lives than average. four out of five started with description drugs and often it was for pain medication. a prescription that we got because of a procedure. could you briefly respond to that i should mark >> s., three quick responses. one on the scope. we will determine whether adjustments are needed. two on the practice issue. overall it is budgeted to show it to describe. overall a slight shift in the impact table stores the position clinicians base.

specific thank you are focused on the opioid epidemic. as you know, for the first time in u.s. history but it goes in the ussr light expectancy is going down and is driven by it. issues. we will abide a comments including classes of drugs, what you have named here is $16.80 proposed orders than they are a low cost as the name for the percentage in greece looks large. we will have to look at that specifically and determine across classes of drugs and you named one any adjustments needed in the proposals. >> just briefly, one comment may be in writing. it's knowledge that sample, a big problem right now around the country. it is what is causing more overdoses in hawaii and is right now. as i look at this, it receives a 2000% in recent reimburse them

under this model. i am very concerned that we are going to incentivize increase utilization rather than the opposite. that is the fixed fee. we can give you a formal and to that. >> senator thune. thank you, mr. chairman. thank you for being here. as many of my colleagues have pointed out, the lack of consultation with stakeholders is striking in further indication not only the flawed generation but is the advice entity. i went to attract attention of the authorizing statute, which states that cmi shop has all representatives rather than federal agent he is. at the federal level, it there is hhs rural task force on rural task force and the hhs advisory committee on health and human service is a newly created row house counts a lot dedicated to health policy.

i've been told this unit ordinates that the office of rural health of the to ensure that health care providers can auction to the best of their ability within the boundaries of our statutory and regulatory frameworks. so the question i have is genuine form as to whether c. and then i -- cmmi will ensure what many of us believe is a flight demonstration program will not impact delivery here in rural areas. >> yes, cmmi works close way across the federal government. this proposal went through the standard clear its interaction processes any mention the cms policy task orders that mr. slavik and i established. we think that it's critical for rural issues. as i noted earlier, we made a proposal in rural areas, but we

also noted we were focused on access road areas and access to medications. so we are going to review the public comments now and determine whether any adjustments are needed in rural areas. >> dr. conway, can you detail the feedback he was hit from these entities have mentioned after this hearing or provide the documents you might have regarding the input? >> yes, we can provide input on the process. >> it would be nice to know if in fact those entities have mentioned were consulted and with their feet back since it. i understand. >> it is well known but not all drugs utilize the treatment of their head cheaper alternatives. the question is how will beneficiaries who need these treatments have better access to care when their best treatment option may first or provider into a situation where he can no blog or afford to provide it.

>> so, we would want and i would want personally every doctor, including on a cancer doctor to prescribe the medicine that the patient needs. we believe this proposal maintains access to paid the average house price plus the 2.5% add-on fees plus a fixed fee. however, these are the type of comments we would look close you. if a physician or clinician could show that this is an access can earn, both in the comment. where we would did or whether adjustments are needed, we would consider that. we also propose an exception process, where we propose that this is the patient if the proposal created an access issue, we could make adjustments.

sorry to give you a long and are a mess, that i was asked earlier. i personally get e-mails all the time today for medicare beneficiaries they can access medication. as a practicing physician i care about that deeply and i want patients to have access to the right medicine. at one of the patient to get the medicine they need in every doctor to describe the medicine they need for their patience. those are the type of comments that we will look very close to you. >> and i would just add if you got a provider that can no longer afford the drug and you got musters the treatment at a hospital's outpatient department as a consequence of that, how is that going to increase car sharing, going to impact a patient's ability to receive treatment? >> so i think first we will review first of our comments came in. if you think about a crack this,

i hope that people are the practices looking at it across the board as opposed to one individual drug. if reimburse that goes up in terms of the asp formula proposed, that is obviously revenue to attract this. we are going to look at overall access to medications in the aggregate for the policy and whether adjustments are needed and also in the specifics. .. we acknowledge that and admire

the energy and intellect you bring to a very tough challenge. among comments i've heard about demonstration, why is it so big? we work with demonstrations across the federal government. we always think of the states as laboratories and democracies. why such a large demonstration? >> first, it is a proposal so we will seek comments on the scope and many people have noted that. what we think about in terms of proposals is first a primarily the statutory mission which is to propose models we think have a high likelihood of improving quality and lowering costs. of the geographic scope we need to think about three issues primarily, one, areas were big enough most practices are going to be, the majority of practices within an area, so sort of the geographic site. that it's able to be evaluated.

determine whether they meet criteria, improving quality of our cause. you have to have a sufficiently large sample so that you can about what the model. and three that you're able to comparison groups. geography allows you to compare two other comparable geographies but we look out public comments and determine based on those criteria and the public input whether adjustments are needed. >> my staff gave me a briefing she. just want to read you a short paragraph of a briefing my staff gave me. cms expects, phase one, cms expects proposed demonstration project to incentivize decisions in health care providers to select drugs of better value for cost for patients. leading to savings. something we're all interested in. certain doctors often prescribe higher cost of drugs was a somewhat lower payments while

primary care physicians who may prescribe lower cost drugs will likely receive higher payment. is that a correct assessment? would you talk about that? do you want to modify that? >> yes. said that is from the impactit will, so it is correct. that are relatively modest, quoted earlier, adjustments for oncology and rheumatology. is also adjustments up in the primary care arenas but we published an impact table because we want to be transparent about the current proposals affect. if adjustments are made we were then published a final impact table with the effects across practice types, also urban, rural, the type of issues we care deeply about them want to be transparent. >> all right, thanks. last year medicare part d spent about $20 billion on prescription drugs.

does this sound about right? because shared by seniors, disabled. several drug countries that provide -- incher patience and medicare are getting the best out of and outcomes in return for a fair we enforcement. my question is does the proposed part d demonstration project help semester effectively evaluate value-based payment models for prescription drugs? and the second half of that is, is the first phase of demonstration necessary for advancing these alternative models for prescription drugs? >> yes. so we proposed the two-phase approach. they are proposed as separate arms, if you will, of intervention. and yes, the second phase directly builds on what we've seen and the private sector and are hearing from the private sector about the desire to test value-based arrangements such as

outcomes-based pricing and other methodologies that incentivize higher value and outcomes, hence our proposal. >> you asked a lot of questions. did you anticipate -- was the question you wish had been asked that has not been asked? what would be a good question, why didn't you ask me that one? >> i think -- >> i see your staff writing feverishly behind the. >> they will probably get a better answer later and i will feel bad. the innovation specifically, congress wrote in the innovation center statute, and i will not get this language exactly right. that we cannot limit any benefit to medicare beneficiaries. we are not limiting benefits to medicare beneficiaries. i have said this but to reiterate, we care deeply about access communications,

innovation and better health outcomes. the question we collectively have to work on is how do we propose casts and models to help us achieve those outcomes. sorry for the long answer, but the current system today, i literally get contacted daily from beneficiaries that don't have access to a given medication or don't have access to care in a given area. so if we think the status quo is optimal, i think we are mistaken. and we need to test new payment and service delivery models to improve care for millions of americans. i think we are on a learning path today that is much better than it was three years ago. >> thanks so much. >> senator toomey. >> thank you, senator wyden. dr. conway, thanks for joining us. a couple of caution. we are running well into the votes i want to move quickly. i want to go back to the scope issue because it is something that the concern raised by many of my constituents and by my

reading of the statute. it's, the affordable care act states that seen in my has the authority to test a model addressing and a quote a defined population for which are our deficit in care, end quote. but this rule would change the terms of reimbursement for 75% of all doctors who administer part b drugs under the asp plus six approach. every single drug that is subject to the asp plus six reimbursement as understand it. how could that be consistent with the congressional intent of a defined population? it just seems almost universal, which is not the same as a defined -- how is it a defined population? >> so as you noted the innovation center authority has proposed the test.

he we defined the populace based on geography. did we defined the scope of the geography? a key issue we will evaluate -- >> so i understand, it's true that or, as understand it it, right, there are these different subsets that will undergo different experiments. but almost everybody is involved in this broader experiment in some degree. so the current proposal has three arms and, therefore, does have, as you noted, 75%, approximately, the country in intervention arms. we will evaluate the comments and determine, ma look at issues around the number of farms or intervention in the stood in the geographic scope and what adjustments are needed. >> i which is strongly urge you to focus on a particular issue. i was a with the affordable care act was written by think a lame

and reading of it suggests something much narrower than once contemplated here. second question i have for you goes to the purpose, as i understand it was one of the stated purposes, is to make sure there's no incentive to drive position towards a more expensive alternative than some of alternative, which the current system seems to suggest. in its june report, medpac listed the 10 drugs with the highest part b expenditures. do you know, had fda approved generic alternatives? >> i don't want to put a number and be wrong. >> the answer is zero among the top 10. and so it strikes me that could accept the payment model that drives the docs to prescribe the 10 highest expenditure drugs. it's the fact that there's no

alternative. so if we were to make this change i don't know about is there a concern that could create an incentive for physicians to experiment with off-label use for some purposes? was that a consideration? >> a few comments. so, one, the proposal does not just focus on drugs whether or interchangeable scum if you will. so, for example, as you noted in her changeable to generic are proposing to pay the average sales price which is the average cost of the drug plus 2.5% plus a fixed fee. we are going to look at the pub, to determine if there is adjustments that are needed in debt for not either or in certain settings. the goal is for both high-cost drugs and low-cost drugs but we are paying appropriately for those drugs. ecosystem does have a disincentive we've heard about

from medpac and others on the low-cost drugs, where if it's a $10.60 cisc$10.60 come through s about what that covers the cost of the physician or clinician prescribing said medication. we are trying to remove the financial incentive but still they appropriately for the provision of drugs that you need or other drugs. once again we would want the oncologist or other rheumatologist, physicians and clinicians to prescribe the medicine that they need us to pay, if the physician or the patients received a medicine that they need. >> thanks. >> i think my colleague. dr. conway, we are at the point in the hearing where the choice is really for me to either filibuster until my colleagues get back or to offer a couple of additional questions. i'm going to opt for the second route, and ask you about how

this proposal interacts with other payment reform proposals. it's obvious that there's been progress made over all to moving the health care system to one that moves away from volume, that incentivizes quality and value. you all reached the target of making 30% of medicare payments through alternative payment models. that's a plus, nine months earlier than expected. and, obviously, was called a macro legislation, america access bill, the bill that has this critical program for kids past last year, hugely flawed program with a payment system that rewards doctors are providing high quality cost effective care to patients. i have heard from some providers that the proposed part b drug demonstration could unintentionally discourage

participation in the new payment delivery and reform models such as the oncology care model and the alternative payment models incentivized by the major medicare legislation. what would be your response to those concerns, and how do you envision making sure that this demonstration doesn't in any way discourage participation in the other model programs you all are looking at? >> thank you, senator wyden. we think this proposal aligns with those programs. so specifically to give you an example, the basic construct of macro, and we want to thank congress for that, was to pay physicians and clinicians based on value, so quality, researchers, clinical practice improvement and use of technology. this proposal also aligns with paying physicians and clinicians

based on value. we think they would actually work well together. we do in the evaluation also through difference and different methods of evaluating for one model, the comparison group and another area where it's not, can estimate the effects of various models but what we think is part b model will combine with macro and encourage participation in these new alternative payment models. i will not filibuster but i do want to -- >> go ahead. >> your leadership and of his committee's leadership on delivery system reform has been hugely important. i care choice model were i was with the hospice and palliative care community -- >> i think would be very helpful -- >> with your leadership i want to thank you for that. >> i think it would be very helpful if you could explain in

something resembling english exactly how medicare care choices work. because this is something that i had really been dreaming would be done almost since the gray panther disparate as i understand what you all are doing with medicare care choices is try to make sure eventually, this is a big pilot, eventually every senior in america could have the opportunity to get hospice without giving up the prospect of curative care. you're a physician and a very skilled one. i gather that this also would make it easier for patients and families to time the kinds of choices they make so it's best for them. could you explain how that works? >> you are correct. we are pilot testing the ability

for patients and families to choose and for hospice and palliative care with so-called curative care. it's actually an almost 40 states, and it allows for much more patient-centered choices. i'll actually, if it's okay, use not my own words but in the panel i had the pleasure of sitting between -- who talked eloquently about the importance of this model and that is one of the biggest positive changes in palliative and hospice care in u.s. history. we will continue to modify and learn and refine based input from congress and others, but huge positive step. as he sent and as a physician i've been through that with family members and patients. and it enables much more patient-centered choice and probably, you know, the most powerful once i sat on the other side of me, a gentleman whose

wife passed away and said it away and said if this had been available for her, they would've been able to make better choices that would have more of life with her goals. at the end of the day come it's about patients and families as you know well and have been a leader in making choices for them. >> keep me apprised of this. want to recognize senator cardin. i just wanted understood that that program, the program to provide more choices for older people, that was really born in this room because during the affordable care act, and my colleagues remember this discussion. we constantly heard this nonsense about how you were deaf panels. there were no death panels. and now with medicare care choices, it's very clear that older people are going to have a wide array of choices that allow them to choose what's best for them outline a line with their s about health and religion and morals and all of the other factors that i appreciate your take.

senator cardin. >> thank you, senator wyden. dr. conway, thank you very much. i would want to drill down a little bit as to what your objectives are, particularly as you move towards the second phase of the demonstration to as i understand the first phase, as i was listening to senator portman's question, it's revenue neutral. your those challenges to understand what you're trying to achieve and trying to do it in a way that uses current resources more effectively in dealing with the reasonable costs associated with administering these drugs. the second phase i'm not quite as clear as to your objectives. and that is, is it your anticipation that it will save projected costs? if it's going to say projected costs, do you know the range of your trying to get to in that second phase? >> yeah, so we believe both

phases have the potential to maintain or generate savings and improve quality for patients. and the second phase, as we put in the proposal, we would come forward with, in the future, the specifics around drug classes and that there is arrangements. we have different tools so outcomes-based pricing, risk sharing arrangements, indications, based payment. we would come forward with the classes and proposals, get patient input, consumer input and input from congress and others of those proposals to give a tangible example has come to us from outside cms, is entities that want to be risk sharing arrangements, where if a given drug may lower cost in part a and b. space, we think about how that could've benefits

across the health care sector. so improve quality of applause. we have lower cost sharing for beneficiaries that are selecting certain medications as one of the proposed tools. the goal here is to test an array of tools that have been used in the private sector, to improve quality and lower cost, to test them in the medicare part b program. >> we have seen in previous efforts to impose delivery system changes that are more cost effective, easy better value, that the budget can prevent it from th being implemt the way that it was intended because you need to produce a certain amount of cost savings since i don't have to share in the realities of the budget. do you build into this demonstration the confidence and credibility that you really are looking for value and not just a tap of the cost issues?

>> yeah, so we actually got our statutory authority calls out both quality and expenditures but we focus on quality and patient outcomes first. when we think about new payment model tepco we lead with quality and patient outcomes. we would take that approach as well. what our goal is to maintain access to improve outcomes for patients, it into either maintain or less and expenditures. the statute includes the build of a program improves quality and maintains expenditures, that i can meet criteria for expansion. >> and how do you intend to maintain the stakeholders as you go through into the to face his? >> we are reviewing the comments now, but i would say the principles that we would try to put in place which is through the cost innovation center is robust patient and consumer

input into the models, input from providers and stakeholders across the health system, certainly input from congress. at the end of the day we know that brought input and transparent processes are critical to shaping this work. i mentioned this earlier but we know innovations in the models in all 50 states. thousands of providers, millions of beneficiaries and its deep engagement with the berries participants. our bundled payment model, are voluntary model, 48 states, over 1500 hospitals and physician groups and others redesigning care for patients and improving care and care coordination. that's the kind of engagement we want. >> thank you. thanks, mr. chairman. >> does my colleague have any additional questions? >> i have a lot of comments i think related to the subject, maryland is in a somewhat unique

position, and one of the issues we will need to talk with his impact it has of each state including my own state that it's different for maryland. >> yes. >> i assure you my principal objective is what is getting better value, that outcome. i think the more you can coordinate the better off you are. but i always am concerned that the pressures on the budget or used at times to use well into the programs that used to produce savings rather than to produce better outcome. dr. conway, itt for you word on what you said, that is not the objective. we will be watching this very closely. >> thank you spent i thank my colleague. just one last question from me. phase two of the demonstration seeks to move into this value based arena, which you've heard the i and certainly others have been subject assessable on both

sides of the aisle for some time, believe this is constructive, moving away from clunky volume driven fee-for-service medicine. that's what face two builds on. how does it coordinate with the other laudable goal of precision medicine? in other words, you will seek in the days ahead to really make sure that drugs and treatments. what's striking about this is this means what it sounds like. really is tailored exactly to the needs of a particular individual recognizing that one particular drug or therapy doesn't affect george and harry in the same and doesn't affect george and sally in the same way. tell us if we have a sense of where you're going. how does the phase two in particular in effect built on

the precision medicine initiative? >> thank you for the question. we think it very much aligned with precision medicine and support precision medicine. let me explain how. for example, if you had a new therapy that generates individually better outcomes for patients and your pain base outcomes and value, that actually supports paying for the therapy and the innovation, better patient outcomes it delivered. similarly, indications of-based pricing, you can imagine if you can really tease apart for which a patient does this therapy maximally effective, and then they appropriate for that, it really incentivizes innovation, precision medicine, better outcomes for the specific patients that will benefit from specific therapies. we think a very exciting place to work across the health care system, manufacturers, payers,

providers, patient groups in support of both precision medicine paying for value and better patient outcomes. >> senator burr. >> thank you, mr. chairman. dr. conway, i have great admiration for the role that you play. and it's gotten to be extremely tough for a doc. to defend an agency who says we can determine treatment better than the attending physician. because i think that's what this rule in fact does. you stated that you met regularly with patient and provider groups. have any of those groups that you met with been supportive of this rule? >> yeah, so we continually meet with patient groups, consumer groups, provider groups speed the question is very simple. have any of them been supportive

of the part b role? yes or no? >> yes. >> which are provided for this committee the list of those groups who have come in and said we are supportive of this speak yes to at least we did receive another letter recently but yes, we can provide that information. >> is cms considering withdrawing this rule, yes or no? >> we are evaluating the public comments now and intend to take those comments into account in finalizing the rule. >> is cms considering withdrawing the rule of? >> we intend to take the public comments into account into finalizing the rule. >> are you doing this to save money, or to reach a better health outcomes speak with we are doing it because we believe can both reach a better outcome and maintain or less and expenditures. >> does cms believe they can design a better treatment pathway that a physician can?

>> i believe come as you noted, i'm a practicing physician. i believe physicians care about their patients, and i want physicians and clinicians to make treatment decisions based on what's best for the patient. i would like an agency, the agency's focus on maintaining a patient, a beneficiary received the medicine they need, and that he physician clinician should provide and all instances the medicine that is best for the patient. would you also agree that the location that they get that that is important? >> so -- >> transportation isn't it would issue with health care in this country it is in the veterans administration. it is in medicaid. i believe it is in medicare. so when you limit the role access to these life-saving treatments, have you in fact

battered the outcome speak with we do not want to limit access, including in rural areas. many of my family members are private practice physicians in independent practice. we support independent physician/clinician practice. were proposing a model that we think can support independent physician/clinician practice including rural and small product is that we work to the public comments to determine -- >> i apologize, disincentives that exist in the current system. youdon't consider a disincentive for a local-based delivery point when you are, but when you go to the hospital we will pay you more money. >> this proposal proposed debated same asp plus 2.5% plus a fixed fee both in the hospital

outpatient and physician saving. >> dr. conway, for years ago we did advancing breakthrough therapies for patients acts with the chairman, and my good friend from colorado senator bennet. our objective was to bring forth promising breakthrough therapies as fast as possible including those that would be impacted by what cms is proposing, this bipartisan loss our remarkable success particularly and bringing forward cancer treatment even faster. as a result of the law, in the first four years over 130 drugs have been designated as breakthrough and more the 45 have been approved by fda so far. i fear this demonstration project will jeopardize access to these rigs the drugs just as they become available. can you assure the committee today that your proposal will not negatively impact the success of the breakthrough therapy legislation? >> we believe the proposal

aligns with innovative breakthrough therapies that improve patient outcomes. because the proposal is about focusing on paying for drugs and therapies that generate better outcomes for patients spent my constituents have written me expressing concerns about is cms proposal. from the ceo of an oncology clinic in hickory, north carolina, he said, physicians and caregivers are not prescribing medications to profit themselves. this team in hickory collective prescribing medications and therapies because they work. do you fear providers are profiting themselves versus, versus providing the therapies because they work? >> i would want those physicians to continue to fight the therapies that work for their patients. >> so if they feel like this in some way, shape, or form takes that ability away from them, then you would see a need to

change this legislation? >> we want to review their spending at the public comments because we want the proposal to support access communications for beneficiaries. >> lasting -- >> the gentleman's time has expired. one less question. >> thank you, mr. chairman. and north carolinians suffering from primary immune deficiency and relies on infusion treatments rights of members of my community on medicare and the providers who care for the already face complexities assessing accessing medical care and treatments. they should not have to face the consequences of an initiative eliminates the treatment options. this cost-cutting measure would become a life cutting measure. i urge you to intervene to stop this proposed reimbursement model. that's a patient. i think a patient probably heard from a provider that if this goes through, his impact on you. what do you say as a doc to the

patient with an immune deficiency disorder? >> i would say i wanted to see the medicine they need for the immune deficiency. i was a to the position of wanting to prescribe the right medicine to patients at all times like all physician should. >> and i urge you to really look at this proposed rule. thank you, mr. chairman. >> senator scott. >> thank you, mr. chairman. thank you, dr. conway, for being here today, and certainly you are from a rural part of texas. i'm from a very rural state, south carolina. i think we both have an appreciation and affinity for the health care costs and challenges for people living in rural areas that are absolutely severe. the things that are for my constituents consistently as it relates to this demonstration project is a fear. they are scared. i know your mother is on medicare come as you suggested, mine is as well. or you stated. senior citizens living in rural

south carolina are scared. they are on fixed incomes and we now have a demonstration project that covers the entire nation. what they see as a result of this experiment will be higher prices, less taxes, and perhaps in order to receive the life-saving treatment that they need desperately to stay alive, to see their grandkids one more time, is a two or three hour drive from manning, south carolina, to charleston. and so with great uncertainty, feeling confused and afraid, they write into our offices. one of the more difficult things to do in congress today is to find a way to unite republicans and democrats on a topic.

this demonstration project has done a very good job of creating and giving concerns from republicans and democrats that all sound fairly similar, save one component of the discretion. and my questions are different from the question different so far. codified they are around world access. they are a round where diseases, the impact on the folks who are socially, socially, economically challenged, and folks were concerned that now we are seeing the government practicing medicine and determining value as opposed to the doctors and the patients working together to figure out what to do is the value proposition of their visit to the doctor. i think, dr. conway, we both can

agree that these concerns are fellows ballot concerns given the scope, the magnitude, the impact on citizens. and i believe that your desires, your intentions are good it. frankly, looking for a way as you said to help medicare to be there not only for your mother who is currently receiving the benefits but for your four kids but i think we share the same concern. perhaps with a different outcome. i hope, i would even plead with you on behalf of the citizens of south carolina who are so concerned about this project, to take a second look, a step back from a nationwide implementation that could have dire effects on folks depending on their very certain paychecks, their certain benefit from social security. so just to highlight a couple of areas one question being the

question in the rare disease arena and where patients in my state, sickle cell is a very powerful weapon against so many folks in my state. for patients with sickle cell and other rare diseases, blood transfusions are one of the only methods of treatment. while it is good to blood products are excluded from this one of the demonstration, it is unclear if they would be excluded during phase two of the demonstration. can you clarify for my folks at home? >> so you're right on blood products in the are proposed to be excluded from phase one. and phase two, if we were ever to pose blood products or, we put out a proposal for phase two that we would come forward with the specific drug classes or areas for phase two that we plan to address, receive comment on those areas both public input,

patient consumer input. so our goal is to engage with congress and with the public, and specifically patients, consumers. and if as we did of the proposed rule if there were specific classes or other issues that needed to be addressed and where diseases wasn't an example we named, that we would love to those public comments and consider how best to address those issues. >> mr. chairman, do you have time for me to ask another question speak with everyone else has gotten the next one, so please feel free, senator scott. >> i really appreciate the extra 10 minutes last night i didn't mean that to be funny but anyway. i certainly appreciate the fact that answer my constituents about the amount of time they could spend on the road trying to find the right practitioner, perhaps the right hospital to go to if you're living in manning,

sumter, or in a rural area of south carolina trying to columbia or charleston. it's just not a hop skip and a jump. it's a more serious proposition. i also note obamacare is going to provide a partnership, a ridesharing service for young folks to sign up for the health care law. how can we justify the department going out of its way to transport the young adults to sign up for obamacare when the program you are proposing will limit access for some of our most vulnerable like the elderly and the disabled? have we figured out a transportation sharing program that would help with the impact of transportation in rural areas? >> so for the proposal we would want the proposal to maintain access, including in rural areas, smaller practices, et cetera. me, for patients and physicians

who want to deliver medicines, we want them to receive the medicines when and where and how they want to receive said medicines. we put forward the proposal because without the proposal maintained access and improve quality and could maintain or lower expenditures but when we look at the public comments, including on smaller physician practice issues and rural issues to determine whether adjustments are needed spirit excuse me, mr. chairman, i will stop where i started. i don't doubt the sincerity of the intentions of dr. conway are anyone in his employ. i do want to echo my concerns for my citizens, particularly those in rural areas, those with a rare diseases, sickle cell being among them. those folks who are just naturally strapped. i would like -- it sounds cool but the fact of the matter is it

means that you too much markup for the money he appeared to we talk about people who are seriously challenged, and now very concerned. and as you've heard echoed to the hearing today, the concerned are real because of the intentions are good, the access issues are still real concerns and, frankly, the pricing you may have a static member, 1680 of the impact on those numbers, on the actual cost can be quite high. thank you, dr. conway. thank you, mr. chairman. >> thank you, senator scott. dr. conway, i just want to make sure. you are a pediatrician. ura career employed in the department. you are not a political appointee. i know you've been published in some of the countries leading medical journals spent i am a career employee spent on behalf

of chairman hatch i would ask for colleagues and staff better here than any written questions for the record be submitted by tuesday july 12, 2016. with that the finance committee is adjourned. [inaudible conversations] [inaudible conversations]

>> the senate returns for legislative work tomorrow on capitol hill. they will vote on a judicial nomination and may consider bills did with illegal immigration. live coverage on c-span2. the house will pick up a bill and representing suspected terrorists from buying guns and denying passports to those who support terrorist organizations. c-span will have live coverage of that tomorrow. fbi director james comey is holding a news conference. the fbi and justice department are not say what the topic is about. the c-span will have live coverage at 11 eastern. a group of supreme court reporters will provide an inside look at some of the major cases decided this past term. the d.c. bar is hosting the discussion at 12:30 p.m. eastern.

live coverage on c-span2. we will be live from charlotte, north carolina, as president obama campaign for democratic presidential candidate hillary clinton. this is her first campaign at this with president obama. they're holding a rally at three eastern. at five eastern the house rules committee meets to decide what, if any, amendments will be allowed tomorrow when the house considers gun legislation. the bill would delay gun sales to people on the terrorism watch list. you can see live coverage here on c-span2. >> if we will invest an additional $100 billion into higher education in the commonwealth we've got to change the way we deliver education and expect more for the dollars spent sunday night, gerard robinson talks about the state of education in the u.s. the body of literature that is pretty clear that they're certain courses you should take,

math, science, english. to simply accept students who have not filled the curriculum obligation, to let them into school i think it's a great disservice to them and it's selling the effort of affirmative action which is something i support. >> sunday night at eight eastern on c-span's q&a. >> a german diplomat to the united states joined academics on a panel discussion on the refugee crisis in europe. they talked about the challenges of assimilating millions of migrantsfrom syria, iraq, libya and afghanistan and what steps could be taken to ease the process. this event was hosted by the university of california, los angeles. [inaudible] -- three contributions. the first speaker is laurie brand, a professor of

international relations on middle eastern studies at the university of southern california and the author of the most recently citizens abroad, states immigration in the middle east and north africa and indivl stories, politics and national narratives in egypt and algeria. she will be followed by david fitzgerald, professor of sociology at the university of california-san diego. and most recently the author of calling the masses to the democratic fortunes of races can immigration policy in the americas. and last there will be an intervention by stefan biedermann who is deputy counsel general and counsel for cultural ambassadors of the federal public of germany in los angeles. each speaker will talk for a team of minutes. so please try to confine your remarks to 15 minutes. i will not choose just before the end of the period and then we will have 45 minutes for q&a.

>> thank you so much. good afternoon. i've been assigned the task of speaking about the domestic implications of the refugee crisis on turkey, jordan and lebanon. and given 15 minutes to do that. so i promise i would speak us. let me begin with just a few general remarks. the first is that none of this can be viewed or should be viewed outside the context of what we started calling the arab spring of which develop into something far, far worse anyway, the arab uprising in china. what's happening in this area we also have the dramatic elements in libya and yemen. second interesting characters sick of this crisis at a think

was to in the earlier session, is that the refugees are largely living in urban areas or in rural areas but in towns. in other words, most refugees, are not living in what we think of as refugee camps even within but jordan we see the camps were southern turkey we see the camps but this is much more of an urban phenomenon. and then a third point is that syrian refugee crisis is one of refugees from a middle income country going largely to other middle income countries. before going on to europe, and so the capacities of those countries have to be engaged also unaffected these are middle income countries. having said that then let me turn to my forced march through this with her i will turn first to turkey. again the numbers we talk about any of these three countries are varied, depending on who's

getting the statistics and what month we're talking about because there's movement back and forth as well as outside. the most recent statistics given by turkish officials are 2.7 million syrians. this population is consecrated as one would expect most heavily in the south and southeast of of the country whereas the government does operate refugee camps for about 280,000 refugees. people get access to health care and educational services into one. these camps have waiting lists for people, however and that is because the syrians were outside these camps do not have the same access to assistance to health care or educational opportunities. those people are starting for the basic necessities like shelter and food, let alone a stable job trying to provide for the nfl's. one can't assume that all of these cases even where the syrian conflict to end tomorrow, that large numbers of these people are probably not going to or not going home anytime soon.

me say a little bit about the political context because it's important to understand what's happening in the domestic front. prior to the beginning of the syrianuprising, syria and turkish relations have begun to improve markedly. this was part of president or the policy -- president or to one. yet when the demonstrations began and president assad in syria refused to yield to protesters, relations between the two countries they curated quickly. turkey became one of assad's most virulent opponents. turkey quickly became involved in supporting the insurgency in series with the backing of the united states and conditions continued to deteriorate and read not just an insurgency, we have a full-blown civil war for want of a better word and turkey was implicated in debt. betray one regime has proven to be far more resilient than predictions at the beginning to read the "new york times" and

other reports. fall into much, fallen for less. and it came to pass. turkey has continued cover relatively open, porous border policy that includes a border which, of course, not only with individuals but also ammunition to a rebel groups and some reports even some syrian gas past through turkey to be used not by the government. this game also in the context of the arab uprising, arab spring were initially the turks had sided with parties to associate with the muslim brotherhood. those parties ended up being defeated particularly in the case of egypt, parties that were supported, opposition been supported largely by the king of saudi arabia and uae. turkey found itself isolated in policy in the region. since the death of king abdullah there have been a gradual attempt to try to counter what they see as growing iranian

influence, but relations remain somewhat strange. this civil war has taken a tremendous toll inside the turkey itself. primarily but not exclusively because it has served as one reason why there has been a revival of the kurdish issue in turkish domestic politics. this has taken increasingly on bloody dimensions and, of course, the turkish government rejects any suggestion of a possible of establishing a kurdish policy in northern syria while at the same time most of those were outside view the kurds who are fighting against ices as one of the best forces engage in a fight. is a real contradiction involved. in terms of domestic or intricate what will happen next? there was recently a change in prime minister. parliament elections are likely to take place in the fall. the president is hoping it will obtain additional seats to change the constitution to a made in such a way to enter into a truly presidential one does contribute further to the

authoritarian turn intricate this is inextricable from what's been happening in syria i think. something brief on the economic situation. prior to the outbreak of the uprising of the civil war in syria, southern turkey economic integration with iraq and syria was one of the major successes. the overall volume of trade wasn't that great but it was computing to diminishing the marginalization of the areas bordering o of the country to a complex estimate of reversing that trend. deteriorating situations. baghdad has also periodically blocked trade from turkey to protest some of the positions that ankara has taken. in addition, tourism which is a very important contributor to the gdp entered has taken a terrible hit as a result of the refugee crisis but also as a result of the increasing spill

over into southern turkey of the violence from syria. in terms of government spending on the refugees, in the first five years the turkish government spent something like $9 billion but the amount expended per month has been a gradual increase in to a point of about 500 million per month. it has been engines we're looking at a much higher cost to turkey going forward. in terms of the refugee presence of themselves, the presence of civilians in the south have strained the capacity of turkish schools to absorb intricate string hospitals and other services, housing and food prices have risen. when it comes to the refugees impact on other elements there are differences among analysts. for example, if one looks at, there does appear to have been a positive impact on domestic consumption to a certain degree to which the refugees that contributed to growth but most economists feel that has reached its limit at that this

contribution is not likely to be a lasting one. at the same time one would expect along with his an impact on inflation. and so while the figures are different, it does appear that inflation reaches high refugee populations, inflation is higher than it is than the national average. this is understandably take a greater demand for consumer goods, housing and transportation and so on. as for the unemployment rate, there's always this issue to what extent are refugees creating jobs, to what extent on the displacing people from jobs? the statistics are not always clear what the picture is not completely clear. to our studies that suggest at least 300,000 serious have entered the turkish labor market. so there's some suggestion this is greater, his attitude unemployment rate in turkey but a lot of these jobs are new jobs and also the result of increased anas a result of the increased

presence of the refugees. there's also evidence the place of turks, in the lower levels of the employment market, that they have been displaced from some jobs. some of them have been displaced upward into positions of overseeing refugee. others have lost their jobs. it's a very mixed picture in terms of the economy and in terms of unemployment. let me turn to lebanon. lebanon again on the front lines of this emerging crisis as was mentioned in the initial presentation, the statistics differ company where between one in four or 15 people currently living in lebanon is the refugee. that includes palestinian refugees who have been in lebanon since 1948. anyway, lebanon has the highest per capita refugee concentration in the world. i think it is important to keep

in mind that all countries experiences with refuse they are going to always be shaped by earlier experiences. a disproportionate number of these people lived below the poverty line, both among the serious as well as the palestinians. official lebanese government had an open door policy, vis-à-vis syria's. that can be modified in 2015 when unhcr was instructed to stop registering refugees from syria and then a sponsorship system was put in place a new, more stringent residency renewal regulations were put in place. which then lets syria's open to possible detention, deportation for entering from working or sing without the right paperwork. the political context is very important and who's eluded you in one of the questions. lebanese government is currently, the best one can say

about it is it's in gridlock. lebanon has not held a presidential election since 2008. the president who was elected in, his term expired in 2014 basically lebanon is being governed by the council of ministers of the cabinet were we have different ministries controlled by different sectarian groups which limits the possibilities for cooperation and coordination of policies. the lebanese government historically has been ill inclined to attend to the needs of its own citizenry, much less the needs of refugees and so that has not changed in this particular situation. this absentee state will not feel overly compelled to ease the burden on poor refugees. so you end up with syrians in lebanon, again, the lebanese government does not allow the establishment of any formal camps for people are crammed into rented houses, into an informal settlements. many